Medical Claims Resolution Specialist

UCLA Outpatient Clinics; Los Angeles (CA); Hybrid; USD 43,000 - 85,000; Full time

Job summary

The UCLA Outpatient Clinics seeks a Claims Adjustment Specialist to analyze and process medical claim adjustments, ensuring accurate payment determinations in line with CMS, DMHC, and health plan guidelines. You will support appeals, reconsiderations, and regulatory complaints, identifying root causes of incorrect payments and applying corrective actions to maintain high production and quality standards.

This position offers a competitive hourly salary range and opportunities to impact patient

Responsibilities

• Review and process electronic and paper claim adjustments, including overpayments and refunds.
• Analyze complex post-paid and escalated claims to ensure accurate reimbursement.
• Apply benefit plans, fee schedules, provider contracts, and DOFR guidelines during adjudication.
• Research appeals, grievances, reconsiderations, and regulatory complaints to support timely resolution.
• Identify root causes of incorrect payments and implement corrective adjustments.
• Ensure CMS, DMHC, and internal processing policies are followed.
• Review claim edits and coding updates to validate accuracy.
• Maintain documentation and communicate outcomes with providers, members, and internal stakeholders.

Job description

The UCLA Outpatient Clinics seeks a Claims Adjustment Specialist to analyze and process medical claim adjustments, ensuring accurate payment determinations in line with CMS, DMHC, and health plan guidelines. You will support appeals, reconsiderations, and regulatory complaints, identifying root causes of incorrect payments and applying corrective actions to maintain high production and quality standards.

This position offers a competitive hourly salary range and opportunities to impact patient